Cost effectiveness of contraceptives in the United States

doi:10.1016/j.contraception.2008.08.003

Contraception

Volume 79, Issue 1, January 2009, Pages 5-14

https://doi.org/10.1016/j.contraception.2008.08.003 Get rights and content

Abstract

Background

The study was conducted to estimate the relative cost effectiveness of contraceptives in the United States from a payer's perspective.

Methods

A Markov model was constructed to simulate costs for 16 contraceptive methods and no method over a 5-year period. Failure rates, adverse event rates and resource utilization were derived from the literature. Sensitivity analyses were performed on costs and failure rates.

Results

Any contraceptive method is superior to “no method”. The three least expensive methods were the copper-T intrauterine device (IUD) (US$647), vasectomy (US$713) and levonorgestrel (LNG)-20 intrauterine system (IUS) (US$930). Results were sensitive to the cost of contraceptive methods, the cost of an unintended pregnancy and plan disenrollment rates.

Conclusion

The copper-T IUD, vasectomy and the LNG-20 IUS are the most cost-effective contraceptive methods available in the United States. Differences in method costs, the cost of an unintended pregnancy and time horizon are influential factors that determine the overall value of a contraceptive method.

Introduction

Despite the introduction of highly effective reversible contraceptive methods, nearly half (49%) of the 6.4 million pregnancies each year in the United States are unintended; there were more than 3 million unintended pregnancies in 2001, the last year from which data are available [1]. The direct medical costs of these unintended pregnancies totaled US$5 billion [2].

Contraceptive use saves nearly US$19 billion in direct medical costs each year [2]. In an era of increasingly constrained resources, health-care decision makers are being held accountable for providing health-care services and treatments that optimize value received for resources expended. Currently available contraceptive methods vary greatly in their efficacy and overall cost. Long-acting methods, such as intrauterine contraceptives and implants, have high effectiveness rates that do not depend on compliance or daily usage. However, their usage has been limited [3].

In contrast, user-dependent methods (e.g., condoms, oral contraceptives) may incur pregnancy-related costs that may greatly exceed the method costs themselves. Thus, there is need for good evidence on the costs and effectiveness of different contraceptive options so that individuals can make an informed choice and health plans can provide the right mix of contraceptive options.

In a previous publication on the cost effectiveness of female contraceptives, we showed that intrauterine contraceptives were more cost effective than all other female contraceptive methods [4]. In the present analysis, we update and expand our previous estimates to include no contraceptive method (chance), male contraceptive methods and new market entrants such as implants. In addition, we adjusted the costs associated with unintended pregnancies to account for mistimed pregnancies so that the results would be generalizable to the entire population of women of reproductive age, not just those who had completed childbearing.

Section snippets

Model design

A Markov model was constructed from the health-care payer perspective to evaluate the costs and effectiveness of using 16 contraceptive methods: vasectomy and tubal ligation as well as 14 reversible methods (oral contraceptives), transdermal contraceptive patch, vaginal ring, copper-T intrauterine device (IUD), levonorgestrel (LNG)-20 intrauterine system (IUS), male condom, female condom, injectable contraceptive, implant, diaphragm, spermicides, sponge, withdrawal and fertility-awareness-based

Base case analysis

Any contraceptive method is superior to no method in terms of costs and effectiveness. The average expected effectiveness ranged from 48% to nearly 100% (99.96%). The most effective methods were vasectomy (100%), the implant (100%), tubal ligation (99.8%), the LNG-20 IUS (99.8%) and the copper-T IUD (99.6%) (Table 3). Five-year costs ranged from US$647 to US$4739. The three least expensive methods were the copper-T IUD (US$647), vasectomy (US$713) and the LNG-20 IUS (US$930).

Results at 5 years

Discussion

Using a 5-year Markov model, we examined the cost-effectiveness of contraceptives (including chance, or no method) in the United States from a health-care payer's perspective. The findings from this study highlighted the fact that all contraceptive methods were more cost effective when compared to no method. Results indicated that long-term contraceptives prevent unintended pregnancies without relying on user compliance while providing excellent value for money. The three least expensive

References (46)

TrussellJ.
The cost of unintended pregnancy in the United States
Contraception
(2007)
ChiouC.F. et al.
Economic analysis of contraceptives for women
Contraception
(2003)
BackmanT. et al.
Pregnancy during the use of levonorgestrel intrauterine system
Am J Obstet Gynecol
(2004)
CroxattoH.B. et al.
The pharmacodynamics and efficacy of Implanon. An overview of the data
Contraception
(1998)
LahteenmakiP. et al.
The levonorgestrel intrauterine system in contraception
Steroids
(2000)
EndrikatJ. et al.
Comparison of efficacy, cycle control, and tolerability of two low-dose oral contraceptives in a multicenter clinical study
Contraception
(1999)
JickS.S. et al.
Risk of nonfatal venous thromboembolism in women using a contraceptive transdermal patch and oral contraceptives containing norgestimate and 35 microg of ethinyl estradiol
Contraception
(2006)
BarreirosF.A. et al.
Bleeding patterns of women using extended regimens of the contraceptive vaginal ring
Contraception
(2007)
BaldasztiE. et al.
Acceptability of the long-term contraceptive levonorgestrel-releasing intrauterine system (Mirena): a 3-year follow-up study
Contraception
(2003)
VaughanB. et al.
Discontinuation and resumption of contraceptive use: results from the 2002 National Survey of Family Growth
Contraception
(2008)

XiaoB. et al.

Therapeutic effects of the levonorgestrel-releasing intrauterine system in the treatment of idiopathic menorrhagia

Fertil Steril

(2003)

FinerL.B. et al.

Disparities in rates of unintended pregnancy in the United States, 1994 and 2001

Perspect Sex Reprod Health

(2006)

MosherW.D. et al.

Use of contraception and use of family planning services in the United States: 1982–2002

Adv Data

(2004)

TrussellJ. et al.

Preventing unintended pregnancy: the cost-effectiveness of three methods of emergency contraception

Am J Public Health

(1997)

ChandraA. et al.

Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth

Vital Health Stat 2

(2005)

HatcherR.A. et al.

Contraceptive technology

(2007)

BackmanT. et al.

Length of use and symptoms associated with premature removal of the levonorgestrel intrauterine system: a nation-wide study of 17,360 users

BJOG

(2000)

WestromL. et al.

Incidence, trends, and risks of ectopic pregnancy in a population of women

Br Med J (Clin Res Ed)

(1981)

PetersonH.B. et al.

The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group

N Engl J Med

(1997)

TrussellJ. et al.

The economic value of contraception: a comparison of 15 methods

Am J Public Health

(1995)

FihnS.D. et al.

Association between diaphragm use and urinary tract infection

JAMA

(1985)

AudetM.C. et al.

Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs an oral contraceptive: a randomized controlled trial

JAMA

(2001)

HootonT.M. et al.

A prospective study of risk factors for symptomatic urinary tract infection in young women

N Engl J Med

(1996)

Cited by (265)

Dynamism of andrological surgery in France: Evolution of procedures over 10 years
2024, French Journal of Urology
Andrology and urogenital reconstruction are emerging disciplines in French urology. The aim of our study was to evaluate the evolution of andrological surgical procedures over the period 2013–2022 using national data.
We collected national common classification of medical acts (CCAM) coding data for all procedures involving andrological surgery from the Scansanté internet platform set up by the Technical Agency for Information on Hospitalisation, which collects prospectively from healthcare structures all procedures coded according to CCAM coding. All surgical procedures in andrology were selected. The inclusion period extended from 2013 to 2022.
In 10 years, the number of vasectomies has increased tenfold, with 29,890 cases in 2022. Vaso-vasostomies remain marginal, with 80 cases per year. Trans-identity surgeries are rising sharply. Vaginoplasties have multiplied by 4 (333 in 2022) and masculinising surgeries have multiplied by 10 (234 in 2022). Penile prosthesis surgery has increased slightly over 10 years. The number of testicular biopsies has remained stable over time, as has the number of surgeries for curvature of the penis.
Two andrological surgeries are showing very strong growth: vasectomy and transgender surgery. The emergence of these 2 activities is linked to societal aspirations. Urologists need to be trained to meet this demand.
Grade 4.
Male contraception
2023, Progres en Urologie
La contraception est un enjeu important de santé mondiale, qui demeure dominée par les contraceptions féminines. Des évolutions concernant les contraceptions masculines pourraient permettre de redistribuer la charge contraceptive.
Une recherche bibliographique a permis de faire l’état des lieux sur les options existantes en rappelant les critères d’une contraception optimale, d’établir les principes d’une consultation pré-contraception masculine et de faire l’état des lieux sur les différentes voies de recherche avec leurs avantages et inconvénients.
Les nouvelles options de contraception masculine sont détaillées, qu’elles soient hormonales (androgénothérapies, association de progestatifs et de testostérone) ou non, notamment thermiques, avec les résultats actuels et les voies d’amélioration. Le préservatif et la vasectomie demeurent les 2 seules options validées. Le développement récent de la vasectomie mini-invasive sans scalpel et de techniques d’occlusion permettent de simplifier le geste, de minimiser le risque de complications (douleurs, hématomes, syndrome douloureux post-vasectomie) et d’améliorer l’efficacité. Les questions du regret et des possibilités de reperméabilisation sont également évoquées.
La question de la contraception masculine va de plus en plus s’imposer en consultation chez l’urologue. Celui-ci devra informer le patient comme le prévoit le cadre légal avant vasectomie, et le conseiller au mieux concernant la technique qui sera souvent mini-invasive sans scalpel ; de nouvelles options réversibles devraient également élargir l’éventail des options disponibles en routine, pour aller progressivement vers une équité contraceptive.
Contraception is a major global health issue, which is still dominated by female contraception. Developments in male contraception could help redistribute the contraceptive burden.
A literature search was carried out to review the existing options and the criteria for optimal contraception, to establish the principles of a male pre-contraception consultation, and to review the various research avenues with their advantages and disadvantages.
The new male contraception options are detailed, whether hormonal (androgen therapy, combination of progestins and testosterone) or non-hormonal, particularly thermal, with current results and avenues for improvement. Condom use and vasectomy remain the only 2 validated options. The recent development of minimally invasive vasectomy without the need for a scalpel and of occlusion techniques has simplified the procedure, minimised the risk of complications (pain, haematomas, post-vasectomy pain syndrome) and improved efficacy. The issues of regret and the possibility of repermeabilisation are also raised.
The question of male contraception will become increasingly important in consultations with urologists. The urologist will have to inform the patient, as required by law, before the vasectomy is performed, and provide the best possible advice on the technique, which will often be minimally invasive without the need for a scalpel. New reversible options should also broaden the range of options available on a routine basis, with a view to gradually moving towards contraceptive equity.
Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Vasectomy
2023, Progres en Urologie
Répondre aux principales questions cliniques que se posent les praticiens et les hommes consultant pour une demande de vasectomie.
La méthode RPC (Recommandations pour la pratique clinique) a été utilisée. Une recherche bibliographique Pubmed sur la période 1984–2021 a identifié 508 références, parmi lesquelles 93 ont été retenues et analysées.
La vasectomie est une contraception permanente, potentiellement réversible. Il s’agit d’une intervention sûre. Les complications chirurgicales (hématomes, infections, douleurs…) sont rares. La fréquence des douleurs scrotales prolongées affectant la qualité de vie est de 1–2 %. La vasectomie n’a pas des conséquences négatives sur la sexualité. La vasectomie est contre-indiquée chez le patient mineur ou présentant un handicap intellectuel ou en cas d’impossibilité d’identifier et d’exposer le canal déférent. Les patients à risque majoré de regret sont les hommes célibataires, divorcés ou séparés, sans enfant et d’âge inférieur à 30 ans. La conservation de sperme sera discutée. Quelle qu’en soit la raison, la loi laisse au chirurgien la possibilité de refuser de pratiquer la vasectomie. Il doit en informer le patient dès la première consultation. L’anesthésie locale devrait être considérée en première intention. L’anesthésie générale peut notamment être envisagée en cas d’anxiété, de sensibilité du patient, et de difficulté prévisible de la procédure. Deux points paraissent améliorer l’efficacité de la vasectomie : la coagulation de la muqueuse déférentielle et l’interposition de fascia. Laisser libre l’extrémité testiculaire du canal déférent paraît diminuer le risque de survenue du syndrome post-vasectomie sans augmenter le risque d’échec, ni de complications. La vasectomie mini-invasive, dont la technique « sans bistouri », paraît associée à un risque plus faible de complications postopératoires que la vasectomie conventionnelle. Il est recommandé de réaliser un spermogramme à 3 mois post-vasectomie et après 30 éjaculations. S’il persiste des spermatozoïdes à 3 mois, un contrôle 6 semaines plus tard est recommandé. En cas de spermatozoïdes mobiles ou de plus de 100 000 spermatozoïdes immobiles/mL à 6 mois (définissant l’échec), une nouvelle vasectomie devra être envisagée. Une contraception doit être maintenue tant que l’efficacité de la vasectomie n’est pas confirmée.
To answer the main clinical questions asked by practitioners and men consulting for a vasectomy request.
The CPR method was used. The clinical questions were formulated according to the PICO methodology. A Pubmed literature search for the period 1984–2021 identified 508 references, of which 79 were selected and analyzed with the GRADE grid.
Vasectomy is a permanent, potentially reversible contraception. It is a safe procedure. A second vasectomy is necessary in only 1 % of cases. Surgical complications (hematoma, infection, pain, etc.) are rare. The frequency of prolonged scrotal pain after vasectomy is about 5 %, and less than 2 % describe a negative impact of this pain on their quality of life. Vasectomy does not have negative consequences on sexuality. The only contraindication to vasectomy is the minor patient. Patients at increased risk of remorse are single, divorced or separated men under the age of 30. Sperm storage may be particularly appropriate for them. Whatever the reason, the law allows the surgeon to refuse to perform the vasectomy. He must inform the patient of this at the first consultation. The choice of the type of anesthesia is left to the discretion of the surgeon and the patient. It must be decided during the preoperative consultation. Local anesthesia should be considered first. General anesthesia should be particularly considered in cases of anxiety or intense sensitivity of the patient to palpation of the vas deferens, difficulty palpating the vas deferens, or a history of scrotal surgery that would make the procedure more complex. Concerning the vasectomy technique, 2 points seem to improve the efficiency of the vasectomy: coagulation of the deferential mucosa and interposition of fascia. Leaving the proximal end of the vas deferens free seems to reduce the risk of post-vasectomy syndrome without increasing the risk of failure or complications. No-scalpel vasectomy is associated with a lower risk of postoperative complications than conventional vasectomy. Regarding follow-up, it is recommended to perform a spermogram at 3 months post-vasectomy and after 30 ejaculations. If there are still a few non-motile spermatozoa at 3 months, it is recommended that a check-up be performed at 6 months post-vasectomy. In case of motile spermatozoa or more than 100,000 immobile spermatozoa/mL at 6 months (defining failure), a new vasectomy should be considered. Contraception must be maintained until the effectiveness of the vasectomy is confirmed.
Use of 52-mg Levonorgestrel-Releasing Intrauterine System in Adolescents and Young Adult Women: 3-Year Follow-Up
2023, Journal of Pediatric and Adolescent Gynecology
To evaluate continuance rates, bleeding patterns, and patient satisfaction with 52-mg levonorgestrel-releasing intrauterine system (LNG-IUS) use in adolescents and young adult women during the first 3 years of use
We conducted an observational prospective study.
Family Planning Service of a tertiary hospital in Brazil
One hundred adolescents and young women aged 16-24 years.
Insertion of 52-mg LNG-IUS for the main purpose of contraception. Follow-up visits were conducted at 12, 24, and 36 months after insertion.
Continuance rates, reasons for discontinuation of the method, and women's satisfaction and bleeding patterns
Among those who were not lost to follow-up, LNG-IUS continuance rates were 89.1% (82/92), 82.9% (72/87), and 75.3% (64/85) in the first, second, and third years of use, respectively. The main reason for discontinuation was acne, followed by expulsion of/malpositioned LNG-IUS. Other reasons for discontinuation were irregular uterine bleeding, dysmenorrhea, and abdominal pain. The amenorrhea rates were 50%, 54.1%, and 39% at 12, 24, and 36 months, respectively. Spotting rates increased during the first 3 years of use (20.8%, 16.7%, and 26.6%, respectively). Adolescents and young women using the LNG-IUS showed high rates of satisfaction, with 93.9%, 100%, and 96.8% of women being very satisfied/satisfied in the first 3 years of use. Only 2 participants who continued using the LNG-IUS reported being very dissatisfied/dissatisfied in the third year of follow-up.
The LNG-IUS showed high rates of continuation and satisfaction in the first 3 years of use in Brazilian adolescents and young adults. Most women reported a favorable bleeding pattern.
Male or female sterilization - the decision making process: Counselling and regret
2022, Sexual and Reproductive Healthcare
To analyze the decision-making process of both male and female sterilization in order to improve counselling and prevent regret after sterilization in the future.
An online questionnaire regarding sterilization (counselling, sources of information and regret) was promoted on Facebook, Twitter and LinkedIn. A total of 1107 men and women who had undergone or considered sterilization in the Netherlands filled in the questionnaire.
A total of 88.9 % of the sterilized group and 67.4 % in the considered group responded that they felt well informed when they considered sterilization. However, less than half of the participants in both groups knew about all different sterilization methods. In both groups participants reported they consulted their partner the most when they considered sterilization. After sterilization 7.7 % reported having regret. Regret was reported more often when participants were sterilized ≤ 30 years. Most important reasons for regret reported by males were complications, pain, a new wish to conceive and divorce/remarriage. Most important reasons for regret reported by females were pain, complications, a new wish to conceive and menstrual symptoms. A total of 21.1 % in the sterilized and 38.0 % in the considered group responded they would have liked to use a decision aid when they considered sterilization.
Findings of this study provide insight in the decision-making process regarding sterilization. There is a lack of knowledge of different methods of sterilization and 7.7% regrets their sterilization afterwards. Furthermore, the results show an importance of developing a decision aid for couples considering sterilization.
Making the financial case for immediate postpartum intrauterine device: a budget impact analysis
2022, American Journal of Obstetrics and Gynecology
Clinical guidelines support inpatient postpartum intrauterine device insertion. However, inpatient placement remains infrequent, in part because of inconsistent private insurance reimbursement.
The purpose of this study was to explore how the payer’s costs and number of unintended pregnancies associated with a postpartum intrauterine device differed on the basis of placement timing.
Using a decision tree model and following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing the planned approach of inpatient vs outpatient postpartum insertion. Using a 2-year time horizon, the probability and cost estimates were derived from literature review. Our primary outcome was the total accrued costs to the payer. Secondarily, we examined the rates of early repeat pregnancy and sensitivity to estimates of key inputs, including the expulsion rates and the intrauterine device cost.
Although an inpatient intrauterine device placement’s upfront costs were higher, the total cost of this approach was lower. Including the costs of managing expulsions and complications, our model suggests that for every 1000 people desiring a postpartum intrauterine device, the intended inpatient intrauterine device placement resulted in total cost savings of $211,100 and the prevention of 37 additional pregnancies compared with outpatient placement. The inpatient cost savings were superior to the outpatient savings, largely because of a known high proportion not returning for outpatient placement and the resulting higher number of unintended pregnancies among the patients desiring outpatient placement. In sensitivity analyses, we found that the total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement.
For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (ie, “unbundle” from the single payment for delivery) inpatient postpartum intrauterine device placement.

View all citing articles on Scopus

^☆: This study was supported by a research grant from Bayer HealthCare Pharmaceuticals, Wayne, NJ, USA.

View full text

Original research articleCost effectiveness of contraceptives in the United States☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Model design

Base case analysis

Discussion

Contraception

Contraception

Am J Obstet Gynecol

Contraception

Steroids

Contraception

Contraception

Contraception

Contraception

Contraception

Fertil Steril

Disparities in rates of unintended pregnancy in the United States, 1994 and 2001

Perspect Sex Reprod Health

Use of contraception and use of family planning services in the United States: 1982–2002

Adv Data

Preventing unintended pregnancy: the cost-effectiveness of three methods of emergency contraception

Am J Public Health

Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth

Vital Health Stat 2

Contraceptive technology

Length of use and symptoms associated with premature removal of the levonorgestrel intrauterine system: a nation-wide study of 17,360 users

BJOG

Incidence, trends, and risks of ectopic pregnancy in a population of women

Br Med J (Clin Res Ed)

The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group

N Engl J Med

The economic value of contraception: a comparison of 15 methods

Am J Public Health

Association between diaphragm use and urinary tract infection

JAMA

Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs an oral contraceptive: a randomized controlled trial

JAMA

A prospective study of risk factors for symptomatic urinary tract infection in young women

N Engl J Med

Original research article
Cost effectiveness of contraceptives in the United States☆